Provider Demographics
NPI:1467561100
Name:HERITAGE OF WAHOO, INC
Entity Type:Organization
Organization Name:HERITAGE OF WAHOO, INC
Other - Org Name:SOUTH HAVEN LIVING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:VETTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-895-3932
Mailing Address - Street 1:1400 MARK DR
Mailing Address - Street 2:
Mailing Address - City:WAHOO
Mailing Address - State:NE
Mailing Address - Zip Code:68066-4023
Mailing Address - Country:US
Mailing Address - Phone:402-443-3737
Mailing Address - Fax:402-443-5867
Practice Address - Street 1:1400 MARK DR
Practice Address - Street 2:
Practice Address - City:WAHOO
Practice Address - State:NE
Practice Address - Zip Code:68066-4023
Practice Address - Country:US
Practice Address - Phone:402-443-3737
Practice Address - Fax:402-443-5867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE694005314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========00Medicaid
NE=========00Medicaid
NE0452200001Medicare NSC
NE285231Medicare Oscar/Certification